Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System

PREFACE......Page 4
CONTENTS......Page 6
FIGURES......Page 8
TABLES......Page 10
EXECUTIVE SUMMARY......Page 12
ACKNOWLEDGMENTS......Page 28
FRAMEWORK FOR THE PATIENT SAFETY EVALUATION......Page 30
ANALYSES PRESENTED IN THIS REPORT......Page 35
SELECTION OF SITES FOR THE COMMUNITY STUDY......Page 38
DATA COLLECTION......Page 41
PHASE I FINDINGS—PATIENT SAFETY INITIATIVES IN THE COMMUNITIES......Page 44
PHASE II FINDINGS—ADOPTION OF SAFE PRACTICES IN HOSPITALS......Page 54
CONCLUSIONS......Page 64
THE SURVEY QUESTIONNAIRE AND PROTOCOL......Page 66
METHODS......Page 67
FINDINGS REGARDING HOSPITAL EXPERIENCES WITH HSOPS......Page 68
FINDINGS REGARDING USE OF SURVEY RESULTS......Page 73
FEEDBACK TO AHRQ......Page 77
CONCLUSIONS......Page 80
CONTEXT......Page 82
SURVEY DEVELOPMENT......Page 84
TESTING OF DRAFT SURVEY ITEMS......Page 86
CONSIDERATIONS FOR FIELDING THE FUTURE SURVEY......Page 92
DISCUSSION......Page 96
SPECIFIC AIMS......Page 98
OVERVIEW......Page 99
OUTCOME TRENDS FROM EXISTING REPORTING SOURCES......Page 100
ANALYZING TRENDS IN ENCOUNTER-BASED OUTCOME MEASURES......Page 107
TRAJECTORY MODELING OF CLINICAL SAFETY OUTCOMES......Page 110
DIFFUSION MODELING OF CLINICAL SAFETY OUTCOMES......Page 114
CONCLUSIONS......Page 118
SETTING THE STAGE FOR ONGOING MONITORING BY AHRQ......Page 122
COMPONENTS OF A SUGGESTED MONITORING PROGRAM......Page 123
CAPABILITIES NEEDED FOR AN EFFECTIVE MONITORING SYSTEM......Page 125
DISCUSSION......Page 130
APPENDIX A. BOUNDARY SPANNERS INTERVIEWED IN THE COMMUNITY STUDY......Page 132
APPENDIX B. CASE STUDIES FROM THE COMMUNITY STUDY......Page 134
APPENDIX C. SUMMARY OF RESULTS FROM ROUNDTABLE DISCUSSIONS ON NQF SAFE PRACTICES......Page 164
APPENDIX D. NQF SAFE PRACTICES NOT INCLUDED IN SURVEY......Page 170
APPENDIX E. FINAL VERSION OF THE SURVEY......Page 172
APPENDIX F. RATIONALE FOR DESIGN OF THE SURVEY ITEMS......Page 202
REFERENCES......Page 226